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Vital Signs Cardinal signs, reflects body’s physiological status Provides information critical to evaluate homeostatic balance Five critical assessments – – – – – Temperature Pulse Respiration Blood Pressure (B/P) (Now also checking the oxygen saturation) Frequency Vital signs are taken at regular intervals depending on unit policy and patient condition. These times may be: • Every 8hrs • Every 4 hrs • Every 2 hrs • Every hour • Every 5-30 minutes • Depending on condition of client or medication administration Vital signs indicate a positive or negative change in clients condition If vital signs are out of range or different from previous recordings, repeat & if using mechanical equipment find a different machine Factors influencing Vital Signs: – Age Gender Medications – Race Heredity Environment – Pain Stress Metabolism – Lifestyle Exercise Components of Vital Signs: • Temperature- regulated by hypothalamus; shows balance between heat gained and heat loss Temperature Temperature- measured by thermometer – Oral, rectal, ,axillary, tympanic, heat sensitive tape – Electric probe with disposal cover – Always designate where temperature is taken as O, R, A, T, tape – Register temperature as C (Centigrade) or F (Fahrenheit) -Mercury thermometers no longer used Temperature-measured by thermometer • • • • Oral Electronic with disposal cover Tympanic- electric probe used in ear Oral, rectal, axillary Heat sensitive tape Temperature variations: – Newborn 36.5-37 C axillary – Infants 3 months 99.4*F axillary – 1 yr 99.7*F axillary After 4-5 yrs old can be taken orally or ear based device – • Temperature variations • Newborns 36.5-37oC 1 year 99.7oF temp taken axillary 4-5 year old taken orally or tympanic 13 years 97.8oF Elderly range between 96.6o to 98.3oF – Taken orally, axillary it unable to close mouth may also use tympanic or heat sensitive tape Pulse Pulse – an index of the heart’s rate and rhythm, shows heart action – Need to evaluate: Rate- number of pulsation in one minute Rhythm- pattern, even or regular; regular irregular; irregular irregular Quality- fullness or strength- reflex stroke volume maybe bounding, very strong, weak/ thready, absent Common Terms Pulse rate may increase or decrease for various reasons (exercise, drugs, lack of oxygen, medical conditions=dehydration, hemorrhage, etc) Tachycardia pulse over 100 BPM. Bradycardia pulse below 60 BPM Pulse located: – – – – – – – – – Carotid- avoid pressuring too hard decreases blood flow to brain Apical Brachial ( site for auscultation of B/P) Ulnar-near pinky finger Radial- easy access near thumb Femoral Popliteal (behind knee) Posterior Tibial-evaluate circulation lower extremities Dorsalis Pedis- evaluate circulation lower extremities Pulses should be felt against bone and using pads of 3 middle fingers DO NOT USE YOUR THUMB NEED A WATCH WITH SECOND HAND Client should be either in supine or sitting position Infants and Children – – – – Newborn= 80-180/min Toddler=80-110/min School age= 50-90/min Adolescent= 50-90/min Blood Pressure Blood pressure (B/P)- is the force of blood against arterial wall Pulse pressure is the difference between the systolic and diastolic pressure (normal 30-50 mm HG Equipment: Stethoscope ( bell and diaphragm); sphygmomanometer Make sure B/P cuff size is based on circumference of the limb When unable to take B/P on arm can take on thigh Factors affecting B/P – – – – – – – – – – Cardiac output Peripheral vascular resistance Elasticity & Distensibility of arteries Blood volume Blood Viscosity Hormones & Enzymes Chemoreceptors Age, sex, weight Body position Activity Normal adult B/P ranges below 120(systolic) and less than 80(diastolic), varies with different people Hypertensive B/P is defined as 140 mmHG or greater systolic; and/ or 90mmHG or greater diastolic Systolic pressure- give data about the condition of the heart and great arteries Diastolic pressure- data about the arteriolar or peripheral vascular resistance Allow 1 to 2 minutes between taking B/P again Respirations • • • • • Respiration is the process of bringing oxygen to the body tissue ( Inspiration) and removing carbon dioxide (expiration) Normal rate of adult 12-18 breaths/min. Newborn 30- (40-60) breaths/min. Older children 20-26 breaths/min. . Common Terms • Tachypnoea rate over 24 breaths/min. • Bradypnea rate less than 10 breaths/min • Apnoea absence of breathing Dyspnoea difficulty breathing Need to assess pattern, rate and depth of clients breathing Rhythm- pattern between inspiration and expiration Quality effort required to breathe Factors affecting respiration – – – – – Age Drugs Stress Emotions Body position Respirations: – – – – – Newborn- 30-60/min Toddler=24-32/min School age- 18-26/min Adolescent- 16-20/min Adults- 12-20/min